Lutheran Medical Center Clinical Reference

Manual

Nursing Student Information

Lutheran Medical Center is located at 8300 W. 38th Ave. several blocks west
of Wadsworth. If you are coming from the east, turn west onto 38th Ave.
The second light you come to, turn left into the hospital grounds. Follow it
to the visitor’s parking lot. If coming from the west, turn east on W. 38th
Ave. You will pass the hospital and reach a stop light on the east end of the
building. You can only make a right turn. Again, follow the road to the
visitor’s parking lot.

FIRE SAFETY
"Mr. Gallagher is wanted" is the code for an actual fire situation. Drills are always announced as drills. The
five steps to the Emergency Fire Procedure are: " R A C E."
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 R escue the patient / evacuate the area.

larm and call 5555 in the hospital (call 911 at other sites). Give your location as accurate
A as possible.
The alarm box is hooked into a computer system that identifies the box and its specific
location to the operator as well as the Power Plant and the Fire Department.

C lose the door. Doors remain closed until the "all clear" is announced over the PA system.

E xtinguish the Fire - if possible.

For use of a fire extinguisher, remember "P A S S."

P ull the pin.

A im the nozzle.

S queeze the trigger.

S weep back and forth at the base of the fire.

ELECTRICAL SAFETY
In patient care areas, knowledge on reporting equipment malfunctions and the purpose of red
electrical outlets is required.

Do's Don'ts
1. Report malfunctioning or damaged
1. Attempt to repair equipment yourself.
equipment immediately.
2. Attach repair tag and remove such 2. Put liquids (drinks, IV solution, etc.) on
equipment from service. top of equipment.
3. Report any equipment that is dropped,
spilled on, etc., even if it appears that the 3. Run over power cords with wheeled
equipment is all right. equipment.

4. Visually inspect all equipment prior to use. 4. Transport monitors or pumps on bedside
Pay particular attention to power cords. tables.
5. Save parts that may break off machines.
Tape them to machine.

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 WORKING WHILE YOU'RE SICK*
Susan Dolan MS RN and James Todd MD
In a hospital setting, the patient population is a primary concern as many of these patients are already
compromised by their current illness. Acquiring a nosocomial infection on top of this can lead to morbidity
and/or mortality. In certain instances, employees and students who are mildly ill and who do work can do
so if the appropriate precautions are strictly adhered to.
Completely
Illness Type Severe Symptoms Mild or Resolving Symptoms Resolved
Symptoms
Respiratory

Fever (>100o), productive cough, Mild symptoms, fever absent, able to Symptom free.
uncontrollable secretions (e.g., unable contain secretions.
to contain runny nose.
Can you work? No - you need to stay home. Yes - wear mask**, WASH HANDS. Yes - WASH HANDS.
Should you care for No - stay home. No - care for low-risk patients and/or Yes - WASH HANDS.
high-risk*/uninfected patients with like-illness, avoid touching
patients? face.
Fever (>100o), vomiting, diarrhea. *** Mild symptoms, infrequent stools. Symptom free.
(Herpes Simplex)Cold Sore (Sore Throat)Pharyngitis Gastrointenstinal

Can you work? No - stay home. Yes - wash hands (esp. after using Yes - WASH HANDS.
restroom).
Should you care for No - stay home. No - care for low-risk patients and/or Yes - WASH HANDS.
high-risk*/uninfected patients with like illness.
patients?

Sore throat, fever (>100o), excudate on Mild symptoms, fever absent, cough absent. Symptom free.
tonsils/throat, cough absent.
Can you work? No. Yes - after you have taken appropriate Yes - WASH HANDS.
- If Strep Cx (+) antibiotics for 24 hours.
- If Strep Cx (-) or No. Yes - wear mask**, wash hands, avoid Yes - WASH HANDS.
no Cx is indicated. touching your face.
Should you care for No. No - care for low-risk patients and/or Yes - WASH HANDS.
high-risk*/uninfected patients with like illness.
patients?
Draining or vesicular lesion(s) on the Lesion(s) crusted. Symptom free.
face or mouth.
Can you work? Yes - wear mask**. Yes - WASH HANDS. Yes - WASH HANDS.
Should you care for No - consult with charge nurse of Yes. Yes.
high-risk*/uninfected nursery areas to determine if need for
patients? employee to work if no replacement
available and patient care would be
jeopardized.

* High-Risk Patients (with non-infectious conditions):

• Moderate to severe BPD. • Immunodeficiency (hypogram, chronic steroids). • Infants < 2 months.
• High risk cardiac conditions. • Chronic pulmonary disease.
** Masks - need to be changed when they become moist and/or upon leaving isolation rooms.
*** Diarrhea - may include one or more of the following:
• More frequent than normal. • Blood, pus, mucous (stool culture • Fever (> 100o). • Water loss.
recommended).
Remember
1. Handwashing is the most effective step in preventing the spread of infection.
2. All staff members who are ill should report to Employee health.
3. If you develop mild symptoms at work, (e.g., scratchy throat, stuffy nose):
• Take appropriate precautions immediately (e.g., mask if respiratory related and WASH HANDS!!).
• If symptoms worsen, notify your supervisor and go to Employee Health.. If you have been exposed to
a known contagious illness (e.g., chicken pox, measles) and you do not have immunity, you need to

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contact Employee Health immediately. You will not be able to work during the incubation period. Should
you develop symptoms, you may not return until it is determined that you no longer are contagious.

DAILY NURSING GUIDE

0640-0645 Review changes in Kardex and medication sheets before report

0645-0715 Report
0715-1000 Head-to-toe assessment:
Vital signs (include Temp. HR., RR. BP.)
Equipment room check, stock with supplies, and straighten room
Cor equipment check
Medications and treatments as ordered
Bath, oral care, linen change
Assist with feeding patient
1000-1200 Catch up on charting. Computer charting entered each hour.
Meds and treatments as ordered
Nutritional support with age-appropriate choices of food and liquids
Developmental support
Play room activities prn
1200-1400 Head-to-toe assessment
Vital signs if q 4 hrs
Assist with nutritional support
Charting
Meds and Tx as ordered. All 1400 meds must be given before leaving for clinical
conference.
Report to CTA before going to conference
Developmental support. Playroom activities prn
1400.1500 Clinical conference:
Room placement to be announced
Try to be on time as there are often guest speakers
1500-1845 Head-to-toe assessment:
Vital signs
Meds and TX as ordered
Total 8 hour I&O
Complete charting
Prepare written draft for report and review with CTA or instructor
Recheck pt. room for adequate supplies
1845-1915 Report

ADDITIONAL CARE THROUGHOUT 12 HOUR SHIFT

* Plan linen, bed change, bath around treatments and rehab schedule. Needs to be completed
by end of day shift.
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 * IV site assessment and maintenance and recording of I & O hourly.
* Continually update CTA on status of your patient, report changes. Developmentally
appropriate interventions (comfort, play, diversional activities)
Weekly Clinical Appraisal

Raven Starr Date:

STUDENT COMMENTS FACULTY COMMENTS

Comment on your preparation for this clinical experience:

Comment on the quality of your written work (nursing care plan,

charting):

Comment on the technical skills you performed:

Comment on your interpersonal skills, caring and rapport

(communication with peers, health care team, faculty, clients and
their families both verbally and non-verbally.

Comment on how you applied your knowledge of growth and

development in your care of the client and family:

Comment on how you set priorities and your ability to adapt to

spontaneous changes during the clinical experience and how you
sought out your own learning experiences.

Comment on any concerns you have or things you would like to

work on in the future:

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 WHERE YOU GET YOUR HOMEWORK INFORMATION

1. Pathophysiology:
Be sure to review your pathophysiology. Your textbook contains lots of information, but you
may need to use the units' teaching files or the library on the 6th floor of the Health Center.
You will encounter many unusual diagnoses, and you will need to know something about your
patient's pathophysiology. If you receive a new patient assignment, you will be expected to
learn about the pathophysiology during the course of the clinical day.

2. History of Present Illness:

This information is obtained from the patient's chart. There is a specific tabbed section of the
chart that will give you this information. You may want to look through some of the most
recent Progress Notes for an update on your patient.

3. Medical Orders From the Kardex:

Use the nursing Kardex to summarize the medical orders. This will give you an idea of what
your nursing interventions will include during your clinical day. If there are procedures or
tests noted on the Kardex, take some time to look them up in a laboratory reference book or
the unit's Policy and Procedure manuals. Before any test or procedure, you will be expected
to read about it in Policy and Procedure manual and review it with your CTA and or/Clinical
Faculty.

4. Vital Signs, Norms, Ranges:

Use the computer to determine what your patient's vital signs have been in the recent past.
Note any abnormal findings (use asterisk or highlight). This will alert you to
problems/potential problems. The norms may be found at the end of the manual.

5. Growth Parameters and Percentiles:

Growth parameters are very important in pediatrics, especially for children under two years of
age. Most growth occurs in the first two years of life. If there are growth problems, it is
important to detect changes in growth parameters and to intervene as soon as possible. If
your patient is under 2 years of age, you should be able to find the child's growth parameters
on the admission data base and/or the computer. Once you know your patient's growth
parameters, determine the percentiles for weight, height, and OFC (occipital-frontal
circumference).

6. Intake and Output Calculations:

Once you know your patient's weight, you can use the formulas to calculate hourly intake and
output rates. Compare the ideal 24-hour totals to the actual totals (if the actual data are
available). Are there any I/O discrepancies or concerns? Most infants and small children are
on STRICT I/O. That means we carefully measure and record everything they take in and put
out. Infants and small children can QUICKLY develop serious fluid/electrolyte problems, and
they require close I/O monitoring.

7. Abnormal lab data:

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 Use the computers to access lab values and lab reference norms for your patients. Note any
abnormal lab values and try to find rationale in your laboratory reference book. Some of the
common values and abnormal lab rationales are in your manual.

8. Developmental Norms:
Your manual has a section on developmental milestones. If your patient is developmentally
delayed, there should be a notation in the physician's admission note about the child's
approximate "developmental age." For instance, you may have a patient who is 4 years old
with severe CP/MR (cerebral palsy/mental retardation). The physician has documented in her
admission note: "MOC states that last developmental assessment on 3/10/98 places child at 4
month-old developmental level for gross motor and fine motor skills. MOC also states that
child socially smiles, laughs at faces and enjoys being held and read to.” You should use 4
MONTH-OLD developmental milestones and tailor your nursing care interventions to the
developmental information you have about this child. During the course of your shift, you will
be able to make observations and evaluate whether you see the child behaving according to
his/her developmental age. You will also need to identify implications for care relative to your
patient's developmental delays. Hospitalization, chronic illness, and acute illness can affect
children's developmental performance, and you will learn how to compare norms/baseline
with your patient’s hospitalized behaviors.

9. Nursing care needs:

After you have done the worksheet and researched the pathophysiology, think about
potential, important nursing care considerations for your patient and the patient's family.
List 3 needs (or more) that you think will be important nursing care issues for your patient.
Individualize these care needs as much as possible. You will soon learn that care needs
change over time, sometimes quickly. Your initial list of care needs will help alert you to
possible care concerns for your patient, but you will have to re-prioritize during the shift.
Your CTAs and Clinical Faculty will help you learn how to use nursing process to constantly
assess, plan, implement and re-evaluate what is happening with your patient.

10. Medication Worksheets:

Use your patient's Medication Administration Record (MAR) sheet to find the medications
ordered for your patient. You are responsible for researching medication information and
doing medication calculations on scheduled and PRN medications.
EXCEPTIONS: You do not need to calculate safe dosage ranges for RESPIRATORY (marked
per RT in the MAR) inhaler/nebulizer medications or safe dosage ranges for heparin flushes.
The hospital uses many medications that have special dosages and applications for our
pediatric patients. The formulary is designed to give information about how to safely and
effectively administer these medications to our patients. For legal and safety reasons, this
formulary or Lexi-Comp program must be consulted for patient medication information.

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CLINICAL PREPARATION WORKSHEET

Student’ Name: Date:

Child’s Initials: Child’s Age: Gender:

Patient’s Dx: Isolation: yes / no Allergies:

Type:
Brief Review of Pathophysiology and History of Present Illness: (Write information on reverse side of page)
Medical Orders from Kardex:

Most Recent Vital Signs Norms for Age Child’s Range Child’s Values % on Growth Curve
(Over the past 36 hrs)
Temp: WT:
Pulse: HT:
Resp: HC*:
BP: * < 2 yrs.
INTAKE AND OUTPUT CALCULATIONS:
Calculated Hourly Fluid Intake Needed: Calculated Hourly Urine Output Needed:

Calculated 24-hr Needs: Calculated 24-hr Needs:

Actual (Past 24 hours) Actual (Past 24 hours)
ABNORMAL LAB DATA:
Test Child’s Value Normals Rationale (Related to Diagnosis)

DEVELOPMENTAL NORMS FOR AGE:

Expected Age Appropriate? Implications for Care
Gross Motor:
Yes No

Fine Motor:
Yes No

Language/Cognitive:
Yes No

Personal-Social:
Yes No

NURSING CARE NEEDS: Prioritized 3 needs you will need to address and one to two interventions:
1.

2.

3.

Author: Roxie Foster PhD,RN (Revised 10/00 by C. San Miguel MS,RN - The Children’s Hospital, Denver) 05/03
CLINICAL PREPARATION WORKSHEET SAMPLE
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Student’ Name: Jane Doe Date: 04/04/02

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Child’s Initials: KS Child’s Age: 13 months Gender: male

Patient’s Dx: New onset RAD Isolation: yes / no Allergies: Amoxicillin

Type: droplet
Brief Review of Pathophysiology and History of Present Illness: (Write information on reverse side of page)
Medical Orders from Kardex: VS q1h while on continuous nebs. Call HO for T> 38.5, RR > 60. Strict I&O. C-R monitor.

Keep O2 sats > 90%. Reg diet. Bedrest while on cont. nebs. IV: D5 ¼ NS + 20 meq KCL. IV + PO =36ml/hr

Most Recent Vital Signs Norms for Age Child’s Range Child’s Values % on Growth Curve
(Over the past 36 hrs)
Temp: 38.8 Ax Av 37 37.9 – 38.8 WT: 9 kg ~ 10th %ile
Pulse: 136 80 – 180 142 – 176 HT: 74 cm ~ 10th %ile
Resp: 56 26 – 34 56 – 62 HC: 44 cm < 5th %ile
BP: 92/50 69-123/38-92 R arm 73/50 – 96/70
INTAKE AND OUTPUT CALCULATIONS:
Calculated Hourly Fluid Intake Needed: Calculated Hourly Urine Output Needed:
0 – 10 kg needs 4 ml/kg/hr 1ml/kg/hr
9 kg x 4 ml = 36 ml/hr 1 ml x 9 kg = 9ml/hr

Calculated 24-hr Needs: 36 ml x 24 hr = 864ml Calculated 24-hr Needs: 9 ml x 24 hr = 216 ml

Actual (Past 24 hours) 1584 ml Actual (Past 24 hours) 715 ml
ABNORMAL LAB DATA:
Test Child’s Value Normals Rationale (Related to Diagnosis)
K+ 5.7 3.5 – 5.5 ? hemolyzed blood sample

DEVELOPMENTAL NORMS FOR AGE:

Expected Age Appropriate? Implications for Care
Gross Motor:Takes a few steps, can hold cup, finger
feeds, likes pull-push toys Yes No Pulls self up; keeps removing neb mask
Need to keep mask on; help from mom
Fine Motor: Can manipulate potentially dangerous Need to safety proof room.
objects; good pincer grasp Yes No

Language/Cognitive: Understands simple commands Continue interaction, knows mom, point to objects
Knows name, one word vocals, uses gestures Yes No and name them.

Personal-Social: Plays by self, selective attachments, Keep teddy bear and blanket from home in crib. Mom
stranger anxiety Yes No to help with care and treatments.

NURSING CARE NEEDS: Prioritized 3 needs you will need to address and one to two interventions:
1. Respiratory Distress – monitor respiratory status, O2 sats, nebs as ordered.

2. Fever – monitor temperature, administer Tylenol as ordered.

3. Stranger Anxiety – Keep familiar objects in room, enlist the help of the parents.

Author: Roxie Foster PhD,RN (Revised 06/01 Bonnie Cavanaugh PhD RN - The Children’s Hospital, Denver) 05/03

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BASIC MEDICATION INFORMATION

For each medication know basic information (route, amount), and determine:

A. Amount to give: This will be based on the concentration used by the pharmacy. This is on the MAR
sheet. DOUBLE-CHECK the pharmacy's calculations.

B. Safety dosage range: Refer to page 27 for practice problems and answers. These are examples to
get you started. Remember: The dosage range calculations are based on your patient's WEIGHT.
The FORMULARY will provide you with necessary information for doing this calculation.

C. IV maximum concentration: If the medication is being given IV, you will need to determine the
maximum concentration or minimum dilution for the safe administration of the medication. This
information is found in the formulary under the "Nursing Implications" section.

D. Why is the child receiving this medication r/t diagnosis? Use the formulary and your knowledge
of the patient.

E. Teaching needs: This will also depend on information in the formulary and your knowledge of the
patient.

You MUST have your homework completed BEFORE clinicals unless there are special circumstances.
This preparation may take several hours the night before clinicals. Because of safety considerations, your
CTA and Clinical Faculty may send you home if you are unprepared. This could result in failure of the
clinical portion of this course.

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MEDICATION INFORMATION WORKSHEET

Drug: Amount Ordered (i.e., mg/ml) / Frequency: Route:
(p. ) (If IV, over minutes)

Calculate amount to give (ml / suppository / tablet):

(Concentration from Pharmacy: )

Safe Dosage Range / kg / dose or day: Weight of Child: Kg Is the dosage safe? π Yes
π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)

Why is the child receiving this

medication related to diagnosis?
The nurse/family should be aware of
what teaching needs?

Drug: Amount Ordered (i.e., mg/ml) / Frequency: Route:

(p. ) (If IV, over minutes)

Calculate amount to give (ml / suppository / tablet):

(Concentration from Pharmacy: )

Safe Dosage Range / kg / dose or day: Weight of Child: Kg Is the dosage safe? π Yes
π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)

Why is the child receiving this

medication related to diagnosis?
The nurse/family should be aware of
what teaching needs?

Drug: Amount Ordered (i.e., mg/ml) / Frequency: Route:

(p. ) (If IV, over minutes)

Calculate amount to give (ml / suppository / tablet):

(Concentration from Pharmacy: )

Safe Dosage Range / kg / dose or day: Weight of Child: Kg Is the dosage safe? π Yes
π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)

Why is the child receiving this

medication related to diagnosis?
The nurse/family should be aware of
what teaching needs?

Revised 05/02 Karen LeDuc, MSN RN CPN CNS The Children's Hospital, Denver

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MEDICATION INFORMATION WORKSHEET

Drug: Acetaminophen Amount Ordered (i.e., mg/ml) / Frequency: Route: PO
(p. 31-2 ) 225 mg every 4 hours PRN (If IV, over minutes)

Calculate amount to give (ml / suppository / tablet): 80 mg : 0.8 ml = 225 mg : X

(Concentration from Pharmacy: 80 mg / 0.8 ml ) 80X : 180
X = 2.25 ml to administer
Safe Dosage Range / kg / dose or day: Weight of Child: 15.7 kg Is the dosage safe? 4 Yes
10-15 mg/kg/dose π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
10 mg x 15.7 = 157 mg/dose
15 mg x 15.7 = 235.5 mg/dose

Why is the child receiving this
medication related to diagnosis?
The nurse/family should be aware of
what teaching needs?
Pain or fever, Temperature of 38.8°C (101.3°F)
Rate of absorption may be decreased when given with food (increased carbohydrates).
Overdose can cause liver/kidney necrosis, GI disturbances. Do not exceed 5 doses in 24
hours.

Drug: Ranitidine Amount Ordered (i.e., mg/ml) / Frequency: Route:

(p. 488-89 ) 15 mg / 0.6 ml every 8 hours (If IV, over 15-30 minutes)

Calculate amount to give (ml / suppository / tablet): 25 mg : 1 ml = 15 mg : X ml

(Concentration from Pharmacy: 25 mg/ml ) 25X : 15
X = 0.6 ml to administer
Safe Dosage Range / kg / dose or day: Weight of Child: 15.7 kg Is the dosage safe? 4 Yes
0.5 mg to 1.0 mg/kg/dose every 6-8 hours π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
0.5 mg x 15.7 kg = 7.85 mg/dose Dilution: final concentration not to exceed 2.5 mg/ml
1.0 mg x 15.7 kg = 15.7 mg/dose 2.5 mg : ml = 15 mg : X
2.5X = 15
X = 6.0 ml (add 5.4 ml of diluent to make a total of 6 ml)

Why is the child receiving this Inhibit gastric acid secretion.

medication related to diagnosis?
The nurse/family should be aware of Use with caution in patients with liver or renal impairment.
what teaching needs? Monitor liver enzymes, serum creatinine, maintain gastric pH > 4.0.

Drug: Gentamicin Amount Ordered (i.e., mg/ml) / Frequency: Route:

(p. 270-71 ) 38 mg / 0.95 ml every 8 hours (If IV, over 30 minutes)

Calculate amount to give (ml / suppository / tablet): 40 mg : 1 ml = 38 mg : X

(Concentration from Pharmacy: 40 mg/ml ) 40X : 38
X = 0.95 ml to administer
Safe Dosage Range / kg / dose or day: Weight of Child: 15.7 kg Is the dosage safe? 4 Yes
2.5 mg/kg/dose every 8 hours π No
(Show safe dosage and, if needed, calculation of maximum or final concentration for IV administration.)
2.5 mg x 15.7 kg = 39.25 mg/dose / every 8 hours Dilution: final concentration not to exceed 40 mg/ml
Therefore, no dilution required

Why is the child receiving this Gram positive staphylococcal infection of the right hand.
medication related to diagnosis?
The nurse/family should be aware of Monitor urine output and serum creatinine. Draw peak & trough levels around 3rd dose. Be
what teaching needs? alert to ototoxicity.
Author: Susan B. Clarke, MS RNC- The Children’s Hospital, Denver Revised 07/03 BMC PhD RN CNS The Children's Hospital, Denver

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PEDIATRIC MEDICATION CALCULATIONS

1. Calculate safe dose (mg/kg)

mg/kg x pt. wt.

2. Calculate amount to administer (ml)

Dose on hand } mg : mg ordered
ml x

3. Calculate final concentration or dilution for IV medications

concentration for administration } mg : mg ordered
ml x

4. Calculate rate of infusion

Volume x 60
Desired minutes

 Remember to consider the amount of flush required to completely infuse the medication
into the patient. Children weighing 6kg or less: use the syringe pump with a tubing
volume of 1.0ml. Baxter pump tubing has a volume of 16ml plus the filter = 20ml to clear
the tubing.

 The medication & dilution are infused together. When the burretrol empties, the flush is
then added to clear the tubing at the same rate.

Variables to consider with pediatric IV medications:

1. Patient weight
2. Patient fluid status/maintenance rate
3. Patient diagnosis (fluid restrictions)
4. Additional medications to administer
5. Volume of IV tubing

After all calculations are made and variables considered; a

nursing judgment is made to safely give the medication.

All pediatric medications are given with supervision!

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 TIPS FOR MEDICATION ADMINISTRATION

ROUTE CONSIDERATION
Otic • Children < 3 years of age, pull pinna down and back.
• Children > 3 years of age, lift pinna up and back.
Nasal • Have parent hold the child across their lap with the child's head down. Place the
child's arm closest to the parent around the parent’s back. Firmly hug the child's
other arm and hand with their arm; snuggle the head between the parents body
and arm.
Eye • Explain the procedure. Tell the child the medication will feel cool.
• Have the child lie on their back with their hands under their buttocks.
• Have the child look up.
• Provide distractions.
Oral • Infants: Administer medication in nipple, follow with 5cc of sterile water.
Medication can also be administered with a syringe and dropper; place the
syringe / dropper between the gum and cheek. Administer no more than 1/2cc
of medication at one time.
• Chewable tablets: Do not administer to children without teeth. Give them
something to drink afterwards.
• Caplets: Do not crush enteric-coated caplets.
• Capsules: Do not open up if medication is sustained - release. Check with
pharmacy before opening any capsules for administration.
• Avoid mixing medications with formula as the infant may refuse the formula
thereafter.
• When mixing medications with food or fluids, use as little as possible, because
they may not be able to finish all the food or fluids.
Rectal • Consult a pharmacist prior to cutting a suppository; the medication is not
necessarily distributed evenly through the suppository (i.e., acetaminophen
suppositories must be divided lengthwise, not widthwise).
Subcutaneous • Usual amount of administration is 0.5 - 1.0cc.
(SQ) • Sites include deltoid, anterior thigh, anterior abdominal wall, or
inter/subscapular region.
• Insert needle at a 90o angle.
• Needle size: Infant or thin child 25 or 26g, 3/8".
Larger child 25 or 26g, 5/8".
Intramuscular • See discussion in this skill station.
(IM) • For the immunocompromised child, cleanse the site with Betadine and alcohol.
• Consider placing a wrapped ice cube on the site for approximately one minute
prior to injection.
Intravenous (IV) • Use as little diluent as needed.
Long-term • May require a special needle to pierce the port (e.g., MediPort requires a Huber
Venous Access needle).
Devices • Certain catheters are above the skin (Groshong catheters) while others are under
the skin (Port-a-Cath, Infus-A-Port, MediPort).
• May require daily or weekly flush to maintain patency (Hickman / Broviac and
Groshong catheters). Implanted ports must be flushed monthly and after each
infusion.
• Above the skin catheters may be damaged by sharp instruments and are at risk
of being pulled out.
• The Hickman / Broviac catheter must be clamped or have a clamp nearby; the
Groshong catheter should not be clamped (contains a two-way valve).

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DEVELOPMENTAL STAGES

INFANT 0-2 MONTHS

1. Physical Development 2. Psychosocial/Cognitive
- hands held in fisted position - needs constant adult supervision
- lifts head 45 degrees in prone position - regards face
- rolls part way to side from supine - visually follows moving person
- tonic neck reflex dominant in supine position - visually fixes on object
- head lag in pulling to sit - tract object
- step reflex - responds to auditory stimuli
- head droops in the prone position
- roots to turns to nipple
- suckling response
- good swallowing pattern
- lip closure present
- will bring hand to mouth

3 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- hands held in open position - needs constant adult supervision
- maintain grasp - tracts to 180 degrees
- bilateral reaching - attempts to locate sound source
- midline play - good suck and swallow coordination
- lifts head to 90 degrees in prone position - regards own hands
- props on elbows - cuddles and conforms when held
- slight head lag when pulled to sitting - recognizes mother/father
- curve in sitting, head bobs - responds to verbal stimulation
- smile response to smile
- vocalizes to social stimulation
- some consonant sounds

4 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- ulnar palmar grasp - needs constant adult supervision
- pivot prone position - reaches for familiar adult
- symmetrical position in supine - laughs out loud
- sits 30 seconds with support at low back - looks at pellet
- light weight bearing in supported standing - attempts to locate sound source for a variety
- plays with own hands of sounds
- brings object to mouth - turns eyes
- anticipates being picked up - turns head

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5 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- radial palmar grasp - remembering object in visual field
- wrist rotation - initiates noise production with rattle
- volitional reach and grasp - smiles at mirror image
- purposeful repetition of activity - expressive babbling
- retains one cube
- props on extended elbows
- rolls from prone to supine
- assists in pull to sifting
- head control in supported sitting
- takes pureed food from spoon

6 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- raking grasps - plays by banging
- transfers objects hand to hand - attention to detail of objects
- lifts head in supine - imitates speech sounds
- rolls to prone from supine - stranger anxiety
- sits 30 seconds with arm support
- eye-hand coordination in reaching
- picks up and retains 2 cubes
- pats and attempts to hold bottle
- gumming action on solid food

7-8 MONTHS
1. Physical Development
- uses thumb in opposition on cube
- unilateral reaching
- inferior pincer picks up pellet
- begins pulling apart activities
- moves from prone to sitting
- belly crawls
- assumes creeping position in prone
- sits alone readily
- takes full weight in supported standing
2. Psychosocial/Cognitive
- needs constant adult supervision
- uncovers toys
- differentiated exploration of objects
- stranger anxiety
- touches and pats mirror image
- chews crackers/semi-solid food
- drinks from cup when it is held for them
- finger feeding
- holds own bottle

9-10 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- reaches with forearm in mid-position - needs constant adult supervision
- begins isolated finger movements - says first words
- puts cube in cup - uses expressive jargon
- looks at pictures in a book - responds to verbal requests and gestures
- creeps reciprocally - imitative play
- goes from creeping position to sitting
- pulls to standing
- lowers self from furniture to floor
- holds spoon
- uses upper lip to remove food from spoon
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11-12 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- adaptive grasp of crayon - needs constant adult supervision
- imitates scribbling - extends to show without release
- voluntary release - plays pat-a-cake
- neat pincer - says mama or da da specifically
- bangs 2 cubes together - social games
- puts 2 to 3 cubes in cup - separation anxiety
- pokes at holes in pegboard
- creeps
- cruises
- walks with one hand held
- turns pages in book

13-15 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- points with index finger - needs constant adult supervision
- spontaneous scribbling - carries or hugs doll
- builds tower of 2 blocks - vocabulary of 1-3 words
- walks alone 2-3 steps - uses 1 word sentences
- falls by sitting - identifies common objects
- uses exclamatory expressions
- gives toy on request
- solitary play
- separation anxiety

16-18 MONTHS
1. Physical Development
- uses both hands at midline
- puts cover on box
- seldom falls
- walks backward and sideways with pull toy
- turns pages 2-3 at a time
- uses stick to obtain objects outside of reach
- builds tower of 3 blocks
- feeds self with spoon, spills
- drinks from cup unassisted
- takes off shoes
2. Psychosocial/Cognitive
- needs constant adult supervision
- uses gestures
- vocabulary of 6-7 words
- selects 2 - 3 common
- points to body parts named
- follows simple instructions
- solitary play
- separation anxiety

19-21 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- circular scribbling - needs constant adult supervision
- builds tower of 5-6 cubes - 2 word sentences
- runs stiffly - begins to indicate need for toilet/change
- squats in play - solitary play
- walks up stairs holding rail - takes pants off
- unwraps candy - takes socks and shoes off
- finds 2 hidden objects - separation anxiety

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22-24 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- holds crayon with thumb and finger - lacks impulse control and needs constant
- imitates vertical crayon strokes adult supervision
- walks with heel toe progression - parallel play
- runs well, avoids obstacles - names object in picture 3 out of 6
- seats self easily - names body parts
- picks up object from floor without falling - turns pages one at a time
- kicks stationary ball - undresses completely
- separation anxiety

25-30 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- snips with scissors - lacks impulse control and needs constant
- copies circular design adult supervision
- copies cross - names 5 pictures
- walks backward 10 feet - understands on, under, big
- stands on either foot momentarily - understands concept of one
- jumps off floor with both feet - understands simple pronouns
- throws ball overhand - selects picture from memory
- builds tower of 8 cubes - pretends to engage in familiar activities
- doesn't share well yet
- wants own way
- separation anxiety

31-36 MONTHS
1. Physical Development 2. Psychosocial/Cognitive
- cuts well with scissors - lacks impulse control and needs constant
- holds pencil with adult-like grasp adult supervision
- walks tip toe for 10 feet - spontaneous greeting
- ascends stairs alternating feet - says first and last name
- attempts to brush teeth - holds fingers up to show age
- rides tricycle - identifies 2 - 3 pictures and action of
pictures
- plays guessing games
- repeats 3 digits
- remembers 3 objects
- spontaneous play
- group play
- sharing
- imaginary playmates
- separation anxiety
- greatest fear is separation from parents and
harm to body including fears of castration
after age 3 and punishment for wrongdoing

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PRESCHOOL (4-5 YEARS OF AGE)
1. Physical Development
- pulse, respiratory rates and blood pressure
decrease
- height and weight remain constant
- first permanent teeth erupt
- right and left handedness firmly established
- walks down stairs with alternating feet
- throws and catches a ball well
- ties shoelace in bow by age 5
- hops on one foot
- uses scissors, pencil and simple tools well
- slight farsightedness and unrefined hand-eye
coordination (not ready for small print)
3. Cognitive
- views world in terms of self and literal concrete
terms
- starts to understand rules and conformity
- may notice prejudices
- still somewhat egocentric but, developing more
social awareness
- understands time in association with daily events
- by age 5 can follow three commands given in a
row
- has a vocabulary of 2,100 words, counts, and
identifies coins
- uses 6-8 word sentences, describes drawings in
detail
20
2. Psychosocial Development
- at age 4 is very independent and aggressive
- show off and tattles on others
- can be selfish and impatient
- greatest fear is separation from parents and
harm to body
- imaginary play very important (may have
imaginary playmate
- at age 5 is less rebellious
- ready to accomplish tasks and wants to do
things right
- has fewer fears
- says first and last name
- imaginary playmates
- relies on adult authority to control world
- cares for self, dressing, brushing teeth, etc.
- play is more cooperative with other children
- will try to follow rules but, may cheat to
avoid losing
- play is very important
- development of conscience
- may view forbidden activities and wishes as
punishable by physical mutilation, body
damage, and castration
- more independent with strangers, less
anxiety with strangers
- at age 4 identifies strongly with parent of
opposite sex
- at age 5 tends to seek out parent of same sex
- improving impulse control but, still needs
constant adult supervision
4. Effects of Hospitalization
- feels loss of control over usual routines
when hospitalized
- difficult to differentiate between reality and
fantasy because of magical thinking and fear
of mutilation
- may think he/she caused the illness/injury
resulting in the hospitalization
- may regress in behavior or become
withdrawn, angry, aggressive,
noncompliant, clingy, or have tantrums
11
SCHOOL AGED (6-12 YEARS OF AGE)
1. Physical Development
- by age 6, height and weight gains slowly
- dexterity increases
- very active
- use hand as tool, draws, prints, colors well
- by age 7, grows at least 2 inches per year
- posture becomes more tense and stiff
- more graceful
- repeats activities to become proficient
- loose teeth and ugly duckling stage
- by age 8, fine motor control is well developed,
movements smoother
- good hand-eye coordination
- can completely dress self
- by age 12, pubescent changes begin
- remainder of teeth erupt
- posture more adult-like
- enjoys hobbies, physical activities, sports
3. Cognitive
- developing concept of time and time intervals
- has 2,550 to 2,600 word vocabulary
- develops complex sentence structure
- uses words to express ideas, feelings
- views world as something to experience or
manipulate
- combines own with others viewpoints
- can relate to past, present, and future
- may still think concretely about some things
(gray areas are difficult for the child to grasp
- by age 12, can separate cause and intent from
outcome
- by age 12, understands body and body functions
- after age 9, understands that illness has multiple
causes
21
2. Psychosocial
- lacks good impulse control until around age
7 years (needs constant adult supervision
until age 7 and then can be less supervised
for short periods only)
- greatest fear is body injury, disability, loss of
control, loss of status
- separation anxiety decreases
- developing sense of industry and
independence
- eager to learn, school activities important
- more emphasis on emotional and intellectual
growth
- greater capacity to express emotion
- can assume independent chores
- peer group important
- playmates often same sex
- by age 12, more self-critical
- develops interest in opposite sex
- family relationships important, but may test
limits
4. Effects of Hospitalization
- loss of control, autonomy, and competence
- may interpret medical procedures as
punishment
loss of contact with peer group may be difficult
- school routines interrupted
11

ADOLESCENTS (12-18 YEARS OF AGE)

1. Physical Development 2. Psychosocial Development
- adult stature by 18 years (female) and 20 years - greater self-direction and competence
(male) - increasing confidence and self-esteem
- puberty changes in females - family group involvement
* see Tanner Stages - peer group involvement
* axillary and pubic hair - increasing ability to be responsible for own
* labia matures actions and make independent decisions
* vaginal discharge - ability to accept others in a diverse society
* breast development - less impulsive behavior
* menstruation - ability to delay gratification
- puberty change in males - ability to give and accept affection
* see Tanner Stages - increasing leadership abilities
* deepening voice - Erikson's self-identity vs. role confusion
* gynecomastia
* axillary, pubic, facial, and body hair (coarsens)
* penile enlargement
* testes enlargement
* nocturnal emission
- acne
- orthodontia

3. Cognitive 4. Effects of Hospitalization

- problem-solving abilities - may struggle with dependence on parents and
- Piaget - concrete thinking to formal operations need for independence
(the ability to conceptualize and hypothesize) - regressive behavior
- school progress

5. Anticipatory Guidance
- accident prevention (drivers ed, swimming
lessons, sports)
- infectious disease (mononucleosis, URI, herpes,
condyloma, hepatitis, gonorrhea, HIV/AIDS)
- sexual activity (knowledge, birth control, safe
sex)
- nutrition
- females (menstruation)
- males (nocturnal emission)
- substance abuse (changes in behavior, grades,
family withdrawal)
- abusive relationships
- suicidal ideations

8/97 Compiled by: Judy Malkiewicz, PhD, RN

05/03

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PEDIATRIC ASSESSMENT GUIDE

A. Physical Assessment Measurements:

1. Temperature (record type).
2. Pulse.
3. Respiratory.
4. Blood pressure.
5. Height or length.
6. Weight.
7. Head circumference. } Value and percentile for age and gender

B. General Appearance:
1. Describe child's activity and alertness.
2. Does the child appear well nourished?
3. Describe quality of voice or cry.
4. Is there anything about child's appearance which is particularly striking?

C. Skin:
1. Color and temperature.
2. Turgor (Skin has resiliency and returns to a normal position after pinching.)
3. Lesions, bruises, abrasions, rashes.
4. Birthmarks.
5. Hair (color, texture, sheen, distribution).
6. Nails.

D. Head:
1. Symmetry.
2. Are sutures or ridges felt? (Ridges may be felt up to 6 months.)
3. Are fontanels open or closed? (Posterior closes by 2 months, anterior by 18 months.)
4. Is head clear of lesions and scaling?

E. Eyes:
1. Pupils:
a. Are they equal and round in shape?
b. Do they constrict and dilate in response to light?
2. Does child follow objects side-to-side, up and down, obliquely? (By 4 months can follow
180o side-to-side.)
3. Do eyes converge when an object is brought close to the nose?
4. Is there a muscle imbalance? (Strabismus may be normal for 6 months.)
5. Are eyes sunken?
6. Are sclerae and conjunctiva clear?

F. Ears:
1. Ears symmetrically placed and well shaped?
2. Hearing appears normal to whispered voice?

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G. Nose:
1. Is there nasal drainage or crusting?
2. Is bridge of the nose unusually flat or broad, considering heredity?
3. Is there pain or tenderness when pressure is applied over sinuses?

H. Mouth:
1. Mucous membranes.
2. Tongue (Symmetry).
3. Condition of gums.
4. Palate.
5. Number of teeth. (Estimate of average number of teeth is obtained by subtracting 6 from
age in months up to 20 primary teeth.)
6. Are cavities apparent?

I. Neck:
1. Is there mobility and symmetry?
2. Is pain evident when neck is flexed chin to chest?

J. Chest:
1. Is chest symmetrical?
2. Lungs:
a. Respiratory rate and regularity.
b. Breath sounds.
3. Heart:
a. Heart rate and quality.
b. Murmurs.

K. Abdomen:
1. Symmetrical, protruding. (Children's abdomens normally protrude until puberty.)
2. Does umbilicus protrude?
3. Bowel sounds in 4 quadrants.
4. Can femoral pulses be felt equally and bilaterally?

L. Genitalia and Anus:

1. Male genitalia:
a. Is meatus at tip of penis?
b. Is meatus clear of any inflammation?
c. Is the foreskin loose (if circumcised)?
d. Is the foreskin constricting (if not circumcised)?
e. Are both testes palpable in the scrotal sac?
2. Female genitalia:
a. Is the meatus and vaginal opening visible?
b. Is there a discharge from the vagina?
c. Is the clitoris small?
d. Is the labia symmetrical, not enlarged or adherent?
3. Anus:
a. Does anal sphincter appear well constricted?
b. Are fissures present?

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M. Extremities:
1. Mobile with full range of joint movement.
2. Of equal length, strength, mobility, and temperature.
3. Legs straight. (Bowing of legs normally up to 2 1/2 years. Knock-knees from 2 to
3 1/2 years.)
4. Walks easily with good balance. (Broad-based gait normally to 3 years.)
S. Hands are symmetrical with no simian crease.
6. Digits of hand are in proportion and not clubbed.

N. Back:
1. Back is symmetrical.
2. Spine straight and mobile.
3. No indentations or tufts of hair noted on spine.
4. Scapulas are at an equal level when standing or when child bends over to touch toes.
5. Iliac crests at equal level.

O. Neurological:
1. Infants:
a. Babinski reflex positive.
b. Hand grasp equal.
c. Tonic neck reflex noted. (Lasts up to 5 months.)
d. Moro reflex noted. (Lasts up to 5 months.)
2. Older child:
a. Fine and gross motor coordination appears normal for age.
b. Senses of touch, taste, smell are intact.
c. Demonstrates age-appropriate language skills.
d. Demonstrates appropriate long and short-term memory for age.
e. Demonstrates ability to do abstract thinking.

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NEUROLOGICAL RECORD

General Comments
A coma score needs to be documented once a shift on every neuro/rehab patient. When "neuro
checks" are ordered by an MD or done on nursing judgment, the entire record should be
completed as often as ordered.

The seizure activity columns are to be left blank if there is no observed seizure activity.

In infants or toddlers with open fontanels, an assessment of the fontanel should be done every
shift, using all descriptors that apply.

Example: Fontanel 0800 - pulsatile, soft, and flat

1600 - pulsatile, soft, bulging
2300 - non-pulsatile, tense, bulging

Coma Score
Reflects the child's general level of consciousness.
• Maximum score = 15.
• Minimum score = 3.
To be documented once a shift on every patient.

Eye Opening (EO) is scored as follows:

(4) Opens eyes independently when awake or to moderate touch when asleep.
(3) Opens eyes only to voice.
(2) Opens eyes only to deep pain.
(1) Does not open eyes to any stimulation.

If both eyes are swollen shut post-operatively, a CC for "cannot check" is written. If one eye is
swollen shut, score based on the response with the functional eye.

Best Verbal (BV) is scored as follows:

(5) Verbalization (cooing, babbling, words/sentences) appropriate to chronological age is
developmentally normal, or if delayed (i.e., signs or communicates in other fashion)
communicates to their norm per caregivers.
(4) Comprehension of directions and verbal response inappropriate or garbles for age or
norm.
(3) Unable to console or calm; child with persistent shrieking crying and agitation.
(2) Moaning or grunting.
(1) No verbal response.

A child who is unable to speak (e.g., tracheostomy) but who is able to communicate should
receive a score reflecting their cognitive ability to communicate.

A child who is crying persistently during an assessment but calms when not bothered should be
scored appropriate to their general behavior rather than to the behavior during the exam.

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Best Motor (BM) is scored as follows:

(6) Withdrawal and attempt to remove stimulus.
(5) Only minimal withdrawal from stimulus.
(4) Response only to touch, pin or deep pain.
(3) Decorticate posturing: upper extremities flexed to midline; lower extremities
stiff and pointed.
(2) Decerebrate posturing: upper extremities extended, pronated away from body, lower
extremities stiff and pointed.
(1) No response at all.

Pupil Size
The column denoting "=, <, >" is to note pupils that may both be in the same size category but
still slightly different. The actual measured size of the five size designations are: P = 1mm; S =
2mm; M = 4mm; L = 5mm; D = 7mm.

Pupil Reaction
Hippus is defined as a rhythmical and rapid dilation and contraction of the pupil.
A CC for "cannot check" can be charted if the child's eyes are swollen shut.

Extra-Ocular Movements (EOM):

Document all letters that apply. Example: F, T, C indicates normal eye movements.
(F) Focus: Appears to focus and fix on object or light.
(T) Track: Follows objects in all four fields.
(C) Conjugate: Eyes move together in following objects.
(D) Disconjugate: Eyes do not move together and gaze is abnormal.
(N) Nystagmus: Involuntary, cyclical movement of eyeball noticed in any field when testing
gaze.

Limb Movements (spontaneous or on command; not reflex):

(F) Full spontaneous movement.
(L) Limited movement; IV board or cast limiting movement.
(N) No movement.
(Fl) Limb is flaccid as in a hemiparesis or hemiplegia.
(P) Posturing, either decorticate or decerebrate.
The type of posturing is noted in the BM column of the coma score.

Seizure Activity
Type is designated as either "C" for a convulsive seizure with any motor component or "N" for a
non-convulsive or absence seizure with staring or unusual behaviors.

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PEDIATRIC BLS GUIDELINES

COMPONENTS INFANT ( < 1 YEAR) CHILD (1 - 8 YEARS)
Airway • Head-tilt / chin-lift. • Head-tilt/chin-lift.
• Jaw Thrust (trauma). • Jaw Thrust (trauma).
Breathing
Initial • 2 breaths at 1.0 - 1.5 sec/breath. • 2 breaths at 1.0 - 1.5 sec/breath.
Subsequent • 20 breaths/min. • 20 breaths/min.
Circulation .
Pulse Check • Brachial / femoral. • Carotid.
Compression Area • 1 finger's width below nipple • Lower third of sternum with heel
line, compress with 2 fingers of one hand.
Compression:
Depth • 1/3 to 1/2 the depth of the chest • 1/3 to 1/2 the depth of the chest
• 0.5 - 1.0 inch • 1.0 - 1.5 inches.
Rate • At least 100 / min. • 100/min. 5:1 (pause for ventilation).

Compression / Ventilation • 5:1 (pause for ventilation).

Ratio Neonates 3:1 with interposed
compressions / ventilation.
Foreign Body Airway • Back blows (up to 5) then chest • Heimlich maneuver up to 5
Obstruction thrusts (up to 5). times.

BLS for HealthCare Providers (American Heart Association) 2001

Reviewed by Cindy San Miguel, MS, RN, 05/2003

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UNDERSTANDING LAB VALUES

Hbq Segs
WBC
> < HCT
Monos
Lymphs
Platelets

Na CL
K Bi/carb < BUN CR
Glucose

EVALUATE THE WHITE BLOOD CELL COUNT WITH DIFFERENTIAL:

Total White Blood Cell Count: Increased = leukocytosis
Decreased = leukopenia

Hemoglobin: Decreased = anemia

Hematocrit: Decreased = anemia

Red Blood Cell Count: Age-dependent

Structural Variations: Anisocytosis = marked variation in size.

Poikilocytosis = abnormal shape (thalassemia,
sickle cell, liver disease)
Basophilic stripping = lead poisoning

RBC INDICES:
MCH (mean corpuscular Hg = color of an average RBC).
normal color = normochromic
too much color = hyperchromic
too little color = hypochromic
MCV (mean corpuscular volume = size of an average RBC).
normal size = normocytic
too large = macrocytic
too small = microcytic
MCHC (mean corpuscular Hg content = average amount of hg on a RBC).

PLATELETS DIFFERENTIAL:
Thrombocytes
Increased in acute infection, iron deficiency anemia
Neutrophils = phagocytosis: Bands & Segs
Lymphocytes
Basophils (inc. in leukemia, irradiation, splenectomy)
Eosinophils (inc. with allergy, parasites)
Monocytes (inc. with TB, Rocky Mountain Spotted Fever, bacterial endocarditis,
monocytic leukemia)

LEFT SHIFT: Increased Neutrophils Bands & Segs = Bacterial

RIGHT SHIFT: Increased Lymphocytes = Viral

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COMMON LAB VALUES and ASSOCIATIONS

 - increased values  - decreased
LAB VALUES Critical Values
(Remember all lab values are not Common Associations with each Lab Value:
absolute - they are ranges!) (Low) (High)
ALBUMIN  dehydration, exercise.
Infant: (4.4 - 5.4g/dl)
 liver disease, severe malnutrition, diarrhea, burns, starvation.
Child: (4.0 - 5.8g/dl)
Adult: (6 - 8g/dl)
AMYLASE  inflammation of pancreas / salivary glands, acute pancreatitis,
38-108 IU/L @ 37o C peptic ulcer.
 chronic pancreatitis, liver necrosis, burns.
BICARBONATE (serum)  alkalosis.
Arterial 21 - 28mmol/L
 acidosis (bicarbonate ion concentration is regulated by the
Venous 22 - 29mmol/L
kidneys).
BILIRUBIN  erythroblastosis fetalis, sickle cell, hepatitis.
Child: direct 0.2 - 0.4mg/dl
 iron deficiency anemia, drug influence-ASA, PCN.
indirect 0.4 - 0.8mg/dl
BUN  dehydration, impaired renal function, GI bleeding, shock.
Infant: (4 - 16mg/dl)
 starvation, severe liver damage, poor absorption-Celiacs, low
Child & Adult: (5 - 20mg/dl)
protein diet, overload of fluids, infancy.
CALCIUM (total serum)  too much dietary intake, hyperparathyrodism, myeloma, 3.0 17
Newborn: (6 - 10.6mg/dl) metastatic carcinoma, thiazide therapy. mg/dl mg/dl
Child: (2.0 - 2.6mg/dl)  diarrhea, extensive chronic infection, bums,
Adult: (2.1 - 2.6mg/dl) hypoparathyroidism, (chronic renal failure pancreatitis).
CARBON DIOXIDE  decreased alveolar ventilation (acidosis).
(partial pressure - arterial)
 increased alveolar ventilation.
Child: (32 - 48mmHg)
CHLORIDE  diarrhea, hypernatremia, renal disease, dehydration,
Infant: (97 - 110meq/1) hyperventilation.
Child: (98 - 106meq/1) prolonged vomiting, burns, ulcerative colitis, gastroenteritis,

diabetes mellitus.
CHOLESTEROL  atherosclerosis, nephrosis, pancreatic disease, increased
Adult Range: (100 - 200mg/dl) dietary intake.
Child: (5 - 100mg/di) poor nutrition intake.

CLOTTING TIME  time - whole bid 1-8 min (glass tubes) 5.15 min (room temp).
(whole bid)
CREATININE  renal failure, shock, urinary tract obstruction, lupus,
< 6 yrs: (0.5 - 0.8mg/dl) acromegaly.
> 6 yrs: (0.8 - 1.3mg/dl)  muscular dystrophy, pregnancy, eclampsia, severe liver
disease.
ESR  collagen disease, infections, cell destruction.
Child: (3 - 13mm/hr)
 polycythemia, sickle cell, rheumatic fever.
Adult: (0 - 10mm/hr)
GLUCOSE (Serum) FASTING  diabetes mellitus, pancreatitis; Cushings, Tepinephrine 40 ~ 300
Newborn: (50 - 100mg/dl) intake. mg/dl mg/dl
Child: (60 - 100mg/dl)  adrenocortical insufficiency, hepatic necrosis.
Adult: (70 - 110mg/dl)
HEMATOCRIT  dehydration, hypovolemia, diarrhea, stress, burns.
Newborn: (30 - 40%)
 acute blood loss, anemias, malnutrition, leukemia.
Child 6-12 yr: (31 - 43%)
Adult: (37 - 49%)
HEMOGLOBIN  dehydration, polycythemia, stress, burns.
Newborn: (42 - 50%)
 iron; deficiency anemia, cirrhosis of liver, hemorrhage.
Child: (30 - 35%)
Adult: (30 - 42%)
IRON (total serum)  hematochromatosis, excessive iron intake, liver necrosis. 300
Infant: (40 - 100ug/dl) ul/dl
 anemia, hereditary immunodeficiency, leukemia, lymphoma,
Child: (50 - 120ug/dl)
nephrotic syndrome.

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LAB VALUES Critical Values

(Remember all lab values are not Common Associations with each Lab Value:
absolute - they are ranges!) (Low) (High)
PCO2  acute respiratory acidosis, hypoventilation. 20 75
Child & Adult (34 - 45) mmHg mmHg
 respiratory alkalosis, hypoxia, hyperventilation, anxiety.
PH ARTERIAL  metabolic alkalosis, GI loss-vomiting. 7.0 7.6
Newborn: (7.11 - 7.36)
 metabolic acidosis, renal tubular acidosis, hypoxia, diarrhea.
Child & Adult (7.3 - 7.45)
P02  breathing oxygenated enriched air.
Child & Adult: (75 - 100 Torr)
 carbon dioxide exposure, anemias, pulmonary disorders.
POTASSIUM  oliguria, anuria, renal failure, acidosis, massive tissue damage 3.0 7.0
Infant: (0. 1 - 5.3 mg/1) (bums). mmol/L mmol/L
Child & Adult: (3.4 - 4.7 mmol/L)  vomiting, diarrhea, malnutrition, stress, injury, dieuretics.

MAGNESIUM  severe dehydration, renal failure, leukemia.

Child: (1.4 - 2.9 meq/1)
 malnutrition, cirrhosis of the liver, chronic diarrhea.
Adult: (1.5 - 2.5 meq/1)
PLATELET  Polycythemia
Newborn, Infant & Child:
 leukemias, aplastic anemias.
150 - 400 x 103 / mm3 (ul)
Adult: (280 - 400,000 mm3)
PT / PTT  SLE deep thrombocytopenia, salicylates, steroids, trauma.
PT: (11- 1 5 seconds)
 immune thrombocytopenia, anemias, pneumonia, allergies.
PTT: (60 - 85 seconds)
RETIC COUNT  hemolysis, hemolytic anemia, hemorrhage.
Child: (0.5 - 2.0%)
 red cell aplasia, renal disease, drug ingestion.
Adult: (0.5 - 1.5%)
SODIUM  dehydration, low total body sodium from excessive sweating, 120 165
Child: (138 - 145mmol/L) glycosuria, mannitol use) coma, Cushings, DI. mmol/L mmol/L
Adult: (136 - 146mmol/L) burns, diarrhea, vomiting, severe nephritis, CHF, SIADH.

TOTAL PROTEIN  dehydration, chronic inflammation.
Child: (6.2 - 8.0gm/dl)
 over hydration, hepatic insufficiency, malnutrition.
Adult: (6 - 8gm/dl)
TRIGLYCERIDES  familial hypertriglyceridemia, nephrotic syndrome.
Child: (5 - 40mg/dl)
 malnutrition.
Adult: (10 - 190mg/dl)
WBC  UTI, bacterial infections, toxic states, tissue damage.
Child: (6,000 -17,000) l wk - 4 yrs
 infectious typhoid fever, systemic lupus, drug reactions.
Older Child: (5,000 - 15,000) 5-15 yr

PRBC'S • Blood packed at a HCT of 70%. A T&C is required.

• Type A may receive A or 0. Type B may receive B or 0.
• Type AB is the universal recipient.
• Type 0 is the universal donor and receives only Type 0.
• Positive may receive negative but negative cannot receive positive.
PLATELETS • A cross match is unnecessary. • Platelets can be given push or drip.
• Negative should receive negative. • The dose is 0.2 units/kg to a maximum of 10 units.
WBC'S • A cross match is needed because of the red cells in the product.
• The Blood Bank should be notified the day prior to administration.
• In the room have Tylenol, Demerol, SoluCortef, Decadron, Benedryl, Epinephrine, 02, and the
Core Cart close by.
• Pre-wet the filter and hang over 20 - 60 minutes. Observe closely.
FFP • ABO group necessary but cross-matching is not.
• If given for clotting factors-it must by used within 4 hrs.
• If given for volume expander it must be used within 24 hours.
ALBUMIN • Comes in 5% and 25% from pharmacy.
• If undiluted use within 4 hrs.
• Administer slowly and observe for shock.

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RBC MCH MCV Normal Urine

Newborn: 5.1 Newborn: 36 Newborn: 103 ph - Newborn: 5.0 - 7.0
Infant: 4.7 - 5.1 Infant: 30 Infant: 90 Child: 4.8 - 7.8
Child > 2 Yrs: 4.6 - 4.8 Child > 2 Yrs: 25 Child > 2 Yrs: 80 Specific Gravity: 1.001 - 1.030
Sugar: None

Normal Arterial Blood Gas

Neonate Child
PH 7.32 - 7.42 7.35 - 7.45
PCO2 30 - 40mmHg 35 - 45mmHg
HCO2 20 - 26mEq/L 22 - 28mEq/L
PO2 60 - 80mmHg 80 - 100mmHg

Cerebrospinal Fluid
Pressure: 40 - 200mm H20. Protein: > 6 months: < 40
Appearance: Clear. Chloride: 110 - 128
Neonates: 8-9 Sodium: 138 - 150
WBC:
> 6 months: 0 SG: 1.007 - 1.009
Glucose: > 6 months: .40
Hazinski, M.F. (1992) Nursing Care of the Critically III Child. Mosby

HCO3 
Pt. Attempting to Compensate
Respiratory PaCO2 
< 35mm Hg HCO3 Normal
No Pt. Compensation
Alkalosis
pH > 7.45
PaCO2 
Pt. Attempting to Compensate
Metabolic HCO3 
> 26 mEq/L PaCO2 Normal
No Pt. Compensation
Acid Base
Imbalance
HCO3 
Respiratory PaCO2  Pt. Attempting to Compensate
> 45mm Hg HCO3 Normal
No Pt. Compensation
Acidosis
ph < 7.35
PaCO2 
Metabolic HCO3  Pt. Attempting to Compensate
< 22mEq/L
PaCO2 Normal
No Pt. Compensation
From: Reese and Eland. Acid / Base Hyperland Stack, University of Iowa, School of Nursing, Iowa City, IA 1988.

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PEDIATRIC NORMAL RANGES

Pulse Respiratory Rate
Age Average Range Age Range
Premature Infant 135 / min 110 - 160 / min. Premature Infants 35 - 60 / min
0 - 24 Hours 120 / min 70 - 170 / min Birth 30 - 60 / min
1 - 7 Days 140 / min 100 - 180 / min 1 Month to 1 Year 26 - 34 / min
1 Month 160 / min. 110 - 188 / min 2 Years 20 - 30 min
1 Mo to 1 Year 125 / min 80 - 180 / min 2 - 6 Years 20 - 30 / min
2 Years 110 / min 80 - 140 / min 6 - 10 Years 18 - 26 / min
4 Years 100 / min 80 - 120 / min 10 - 18 Years 15 - 24 / min
6 Years 100 / min 70 - 115 / min
10 Years 90 / min 70 - 110 / min
12 - 14 Years 85 - 90 / min 60 - 110 / min
14 - 18 Years 70 - 75 / min 50 - 95 / min

Blood Pressure
Age (Years) Systolic Mean Range Diastolic Mean Range
0.5 - 1 90 65 - 115 61 42 - 80
1-2 96 69 - 123 65 38 - 92
2-3 95 71 - 119 61 37 - 85
3-4 99 76 - 122 65 46 - 84
4-5 99 78 - 112 65 50 - 80
5 94 80 - 108 55 46 - 64
6 100 85 - 115 56 48 - 64
7 102 87 - 117 56 48 - 64
8 105 89 - 121 57 48 - 66
9 107 91 - 123 57 48 - 66
10 109 93 - 125 58 48 - 68
11 111 94 - 128 59 49 - 69
12 113 95 - 131 59 49 - 69
13 115 96 - 134 60 50 - 70
14 118 99 - 137 61 51 - 71
15 121 102 - 140 61 51 - 71

Temperature: 36 – 375; Fever = 385C (101.5F)

Intake and Output

Maintenance Fluid Intake Daily Calorie Requirements
0 - 10kg weight needs 4ml/kg/hr Age Kcal/kg/24 hrs.
11 - 20kg weight needs 2ml/kg/hr Premature 110
additional
21kg plus weight needs 1ml/kg/hr Birth - 6 Months 117
additional
(E.g.: 23kg child needs 10kg x 4ml plus 6 Months - 1 Year 108
10kg x 2ml plus 3kg x 1cc = 63ml/hr) 1 -10 Years 80
10 - 18 Years 50 - 80

Minimum Urine Output Normal Stool Output

1 – 2ml/kg/o Less than 20gm/kg/24 hrs

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GUIDELINES FOR GIVING REPORT

DURING CLINICAL ROTATIONS

These two suggested formats come from compilation of various forms from clinical faculty. Use these to guide your
"giving report." Clinical faculty will assist you and offer suggestions.

EXAMPLE 1
• Speak clearly and loudly.
• Summarize your patient’s status and care concisely, so be brief.

Introduction:
• This is (Your Name) , (Name of University) nursing student.

Patient Information:
• Patient name.
• Room number.
• Age.
• Medical Diagnosis (diagnoses).
• Medical or surgical treatments.
• Surgical treatments - helpful to give surgery date and/or post-op day.

Problem or main concern regarding your patient's course of stay:

• Any changes from previous reports.
• Unusual reactions.
• PRN meds given - drug, time, and patient response.
• Treatments or procedures carried out.
• Unusual assessment findings.
• Concerns with I & O.

Review of IV or other parenteral therapy:

• Type of therapy (maintenance or "unusual" such as Heparin, insulin, etc.).
• cc/hr ordered.
• Amount of IV or other parenteral therapy that is "up" for the next shift.

Briefly review Kardex if necessary.

• Dietary.
• Intake and output.
• Treatments.
• Mobility or activity status.
• Oxygen therapy.
• Special procedures / lab work.

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EXAMPLE 2
• Patient name_________________________ • Room___________________________
• Age (days, months, years)_________
• Hospitalized on ___________ for (diagnosis or reason for hospitalization)_____________
BRIEF ASSESSMENT
• General Appearance:
- activity - interactions with POC / RN
- well nourished - developmental level

• Neurological:
- alert - deficits - speech, ROM - AVPU
- responsive - neuro checks - paresthesia

• Respiratory:
- reg any adventitious sounds (effort, aeration, color,
- unlabored respiratory effort respiratory rate, breath sounds)
- symmetrical - sputum
- breath sounds clear to auscultation (BS CTA) - oxygen
- equal aeration - pulse oximetry

• Cardiovascular:
- heart tones strong and regular edema
- apical for 1 minute with S1 and S2 IV fluids and sites
- periph pulses (+1 to +3) C-R monitor
- cap refill time (CRT) <2sec

• Gastrointestinal:
- abdomen soft - bowel sounds (active or hypoactive) parenteral / NG
- nontender - BMs feeding
- diet

• Genitourinary:
- frequency and amount (in cc's) description - discharge
- dysuria - specific gravity (sg)

• Musculoskeletal:
- active ROM - edema deformities casts
- weakness - inflammation traction - CMS checks
• Skin / Lymph:
- warm and dry (W & D) - rash - ulcers
- color - intact

• Psych / Social:
- appearance - verbalization - affect - mood appropriate
- behavior - communication
• Vital Signs: Summarize ranges for shift.
- T:__________ - P:__________ - R:__________ - BP:__________

• Intake / Output: __________ / __________

• Specific Kardex Information: (dressing change, respiratory treatments, etc.)

• Medications: Note if difficulty with administration or support measures required. Include PRN
meds and patient response.
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• Important Remarks:
• Laboratory Results:

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CLINICAL EVALUATION DIRECTIONS

Your midterm and final evaluations will be determined by your adherence to professional
standards of behavior and your weekly self-evaluations. You must complete a WEEKLY
CLINICAL APPRAISAL each week with a detailed description of what you
accomplished during the shift. The more you say about yourself, the more your faculty
will be able to review with you and to comment on. This should be filled out during the
course of the shift and turned in before you leave at the end of the day. You must make
enough copies for each clinical week!

MIDTERM:
A conference may be held at the discretion of the clinical faculty.
NOTE: CU students will receive written evaluation at midterm.

FINAL:
Your Clinical Faculty and you will complete a final evaluation. Clinical Faculty may add
additional comments to your Final Evaluation sheet. Clinical Faculty will provide
specific requirements for final evaluation.

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